NURSING PRACTICE III
Situation 1: Anthony, 55 years old and a music teacher sought
admission to the hospital because of laryngeal tumor. The
client is scheduled for total laryngectomy.
1.
Before the nurse can develop a relevant care plan,
the nurse understands that in post-laryngectomy, the
trachea and the esophagus are permanently
separated. Therefore, which of the following will the
nurse expect?
A.
B.
C.
D.
2.
Pre-operatively, the nurse identified the nursing
dagnosis, “Knowledge Deficit: Post-operative
communication strategies”. Which of the following is
a relevant nursing intervention?
A.
B.
C.
D.
3.
Position client to Fowler’s
Reassure the client that he is doing fine
Suction the tracheostomy tube
Report to the surgeon
Which of the following expected outcomes for the
patient is most relevant for the nursing diagnosis “At
risk for imbalanced nutrition related to impaired
swallowing”?
A.
B.
C.
D.
5.
Clarify information on purpose, anticipate
benefits and consequences of total
laryngectomy
Explain that total laryngectomy results in
loss of ability to verbally communicate
Arrange a visit to a post-laryngectomy client
who effectively uses an alternative form of
verbal communication
Illustrate means of communicating postoperatively
In the immediate post-operative period, the nurse
assesses coarse, high-pitched sound on inspiration
by listening over the trachea with a stethoscope. The
nurse should immediately
A.
B.
C.
D.
4.
No risk of aspiration during swallowing;
speech is lost
Normal speaking, breathing and swallowing
are restored
Unable to communicate with difficulty of
swallowing and breathing
Permanent tracheostomy created; normal
speech is lost
Appropriate body weight maintained
Fear of choking relieved
Oral intake increased
Swallowing of soft foods facilitated
The nurse is preparing Anthony for discharge. The
following are instructions regarding stoma and post
laryngectomy care except
A.
B.
C.
D.
Avoid exposure to persons with upper
respiratory disease
Instruct client to assume supine position as
necessary
Avoid swimming and use care when using
the shower
Prevent foreign body from entering the
stoma
A.
B.
C.
D.
8.
6.
The nurse who effectively analyzes the
communication process recognizes the messages are
A.
B.
C.
D.
7.
Connotative and denotative
Learned and unlearned
Verbal and non-verbal
Native as well as foreign
Basically, communication is part and parcel of
planning to manage client care. Which of the
following skills should be included? Select all that
apply.
1. Focusing
4. Clarifying
2. Observing
5. Responding
3. Attending
6. Teaching
4,
4,
5,
3,
5
5
6
4
Countersigned by the receiving RN
Signed by the physician who gave the order
Signed by the resident physician on duty
Countersigned by the medical doctor
To facilitate effective communication between an
immediate post-operative client and the nurse,
he/she should
A.
B.
C.
D.
Maintain a clam attitude and just care for
the client as needed
Encourage the client to discuss feelings/pain
or discomfort openly
Observe non verbal cues
Assist the client to comfortable and safe
position while he/she explains what measure
are being done
10. The nurse instructs the nursing attendant to perform
cleansing enema until the return flow is clear. The
nursing attendant understood the instruction when
she says, “I will
A.
B.
C.
D.
Call you when the return flow is clear”
Stop the enema only if the return flow is
without formed fecal material”
Need 1 liter of tap water to have clear
return flow”
Put the client in left Sim’s position to
achieve the desired return flow.”
Situation 3: Post-operative infection complication is still a
concern in surgical client’s care. Hospital staff needs to review
practices to adhere to the standards of care to improve quality
and safe care delivery.
11. Nurse Mercy is setting up for an emergency
caesarian section. The linen packs were damp
although these were just taken from the sterilizer.
The nurse’s appropriate action is
A.
B.
C.
D.
Bring the linen packs back to the Central
Supply section for quality control
Change the damp linen pack
Open the linen pack and allow to dry
Do not use the damp linen
12. The clinical instructor assigned a nursing student to
assist the operation. When the nursing student
entered the OR suite, her curly long hair was not
covered by the head cap. What would the circulating
nurse do?
A.
B.
C.
Situation 2: The communication process is essential to the
manager or leader in supervising client care
3,
3,
4,
2,
The most controversial way of communicating
doctor’s orders is by phone. It becomes valid and
legal only when
A.
B.
C.
D.
9.
1,
2,
3,
1,
D.
Welcome the nursing student to the OR
Request the clinical instructor to tell the
nursing student to use the head cap
properly
Assist the nursing student to tuck-in all her
hair inside the head cap
Do not allow the nursing student to scrub in
13. After the surgeon finished doing the surgical hand
scrub, she came in to the OR suite swinging her
hands casually. The scrub nurse should do which of
the following appropriate action?
A.
B.
C.
D.
Offer a sterile towel to dry her hands
Serve the surgeon her sterile gown and
gloves as usual
Tell the circulating nurse to pour alcohol
70% to the surgeon’s hands.
Remind the surgeon to scrub again
14. When the intern-in-charge did the skin prep and
catheterized the client, the circulating nurse noticed
when the intern withdrew the catheter from the
vagina. What is your appropriate and immediate
action?
A.
B.
C.
D.
Stop the intern and do the catheterization
yourself
Offer to change the catheter
Alcoholize the tip of the catheter before
reinserting the catheter
Hold the hand of the intern to stop him from
reinserting the catheter
15. After the last stitch, the surgeon is ready to apply
dressing to the incision wound. Which of the
following does the nurse expect the surgeon to do?
A.
B.
C.
D.
Remove his gloves and apply the dressing
Apply the dressings and tape and then
remove his gloves
Put the dressings and remove his gloves to
apply the tape
Tape the dressing and remove the gloves
Situation 4: A 57-year-ols male client, post Billroth II was
admitted to the Post Anesthesia Care Unit (PACU) from the OR.
The client is still sedated but responsive to commands. He has
a nasogastric tube draining orange-yellow fluid to a drainage
bottle
16. The nurse who admitted the patient recognizes that
Billroth II procedure means
A.
B.
C.
D.
Enterostomy
Esophagojejunostomy
Gastroduodenostomy
Gastrojejunostomy
17. After admitting the patient to the PACU, the first
action of the nurse would be to
A.
B.
C.
D.
Assess patency of the airway
Check the rate of the IV infusion
Monitor the vital signs
Assess the clients pain
18. As the nurse monitors the client, she notices a bright
red spot on the dressings which measures 4cm in
diameter. The nurse should initially do which
appropriate nursing intervention?
A.
B.
C.
D.
Change the top dressing
Continue to monitor the vital signs
Notify the clients surgeon of a potential
hemorrhage
Assess the presence of a drain
19. In assisting the client to do deep breathing, coughing
and turning to the sides on the first post-operative
day, which nursing action would be most helpful for
the client?
A.
B.
C.
D.
Restate the importance of respiratory
exercises
Give the client reassurance that can he can
cough, breathe deeply and turn to sides
safely
Administer the prescribed analgesic round
the clock as prescribed
Apply abdominal splint (pillow) while
coughing
20. The client complained of abdominal pain, nausea and
vomiting with abdominal distention. The nurse
anticipates which of the following priority
management after referring to the surgeon?
A.
B.
C.
D.
Gastric decompression
Possible surgery
Endoscopy
Rectal tube insertion
Situation 5: The behavior or actions of any professional nurse
especially while on duty are often the reflection of their
values.
21. Mrs. C. Serdenio is currently enrolled in the master’s
program at the State University and is currently
writing her thesis. She applied as a chief nurse in St.
John’s hospital and was accepted. Since her
assumption to office, she has been signing
documents as master’s graduate affixing “RN, MAN”
to her name. the action of the chief nurse constitutes
A.
B.
C.
D.
Misrepresentation
Malpractice
Personification
Misdemeanor
22. The charge nurse reported to the chief nurse that the
Demerol 50 cc vial inventory has been incorrect for
the last 24 hours. The most appropriate action of the
narcotic nurse is:
A.
B.
C.
D.
Log every injection of Demerol
Make fraction dosage like 0.5 ml as 1 ml
Demerol inventory must be checked every
endorsement by the narcotic nurse
Review endorsement of clients who received
Demerol within the last 24 hours
23. A staff nurse was found charting blood glucose result
without actually doing the procedure. What is the
appropriate initial action of the senior nurse?
A.
B.
C.
D.
Write and submit an explanation and
reprimand as necessary
Go on leave without pay
Write an incident report
Explain to the patient
24. While making your PM shift endorsement, you saw
the nursing attendant receiving a package from a
patient’s watcher. Your appropriate action would be
A.
B.
C.
D.
Reprimand the nursing attendant right away
Remind the patient that gift giving to any
hospital staff is not allowed
Review with the nursing attendant the
hospital policy
Endorse to the incoming shift for proper
action
25. The Code of Ethics states that the nurse’s primary
commitment is to the client whether an individual of
family, group or community. Which nursing activity
would best demonstrate the ethical principle called
justice?
A.
B.
C.
D.
The nurse providing care on a “first come –
first served” basis
Referring the client for evaluation to the
social worker on duty regarding her socioeconomic status
The client’s preference is least considered
The nurse’s providing care to maximize
health according to available resources
Situation 6: Nurse Fely is in charge of a client who was
admitted for management of acute episode of cholecystitis.
26. Nurse Fely did her admission. She understands that
the pain is characterized as
A.
B.
C.
D.
Tenderness that is generalized in the upper
epigastric area
Pain in the left upper quadrant radiating to
the left shoulder
Tenderness and rigidity at the left epigastric
area radiating to the back
Tenderness and rigidity at the upper right
abdomen radiating to the midsternal area
27. To confirm the diagnosis of cholecystitis, the
attending physician ordered a procedure that can
detect gallstones as small as 1 – 2 cm and
inflammation. The nurse would prepare the client for
which specific diagnostic procedure?
A.
B.
C.
D.
Cholangiography
Ultrasonography
Gall bladder series
Oral cholecystogram
28. The diagnosis was confirmed as cholecystitis with
gallstones. The doctor prepared the client for the
removal of the gallbladder. The client asks the nurse
how the procedure will affect digestion. The nurse’s
most correct response would be
A.
B.
C.
D.
Removal of the gallbladder would
significantly interfere only with the digestion
of fatty foods.
Removal of the gallbladder does not usually
interfere with digestion
The body will adjust in due time
Removal of the gallbladder usually
interferes with digestion but can be
remedied by dietary modifications
29. Reviewing the laboratory findings of the client, the
nurse would found which findings are elevated?
1. White blood cell count
2. Total serum bilirubin
3. Alkaline phosphate
4. Red blood cell count
5. Cholesterol
6. Serum amylase
A.
B.
C.
D.
1,
2,
3,
1,
2,
3,
5,
2,
and
and
and
and
3
4
6
6
30. A T-tube was inserted and the physician ordered,
“Monitor the amount, color, consistency and odor of
drainage.” Which of the following procedures can the
nurse perform without the doctor’s order?
A.
B.
C.
D.
Clamping
Aspirating
Irrigating
Emptying the drainage
Situation 7: Mary Rose, 16 years old, is admitted to the
hospital for observation due to vague epigastric pain. The
doctor’s clinical impression is appendicitis.
31. Based on the initial manifestation on admission, the
nurse is looking for positive manifestations of
appendicitis which includes the following except
A.
B.
C.
D.
Abdominal tenderness on palpation
Low grade fever
Thrombocytopenia
Nausea and vomiting
32. A positive sign of appendicitis is localized and
rebound tenderness on palpation at which quadrant
of the abdomen?
A.
B.
C.
D.
Left upper quadrant
Right upper quadrant
Left lower quadrant
Right lower quadrant
33. The client is scheduled to undergo appendectomy.
Preparation for appendectomy includes the following:
1. Intravenous infusion
2. Laxative
3. Pubic area shaving
4. Enema
5. Shower
6. Pain medication
A.
B.
C.
D.
2,
1,
1,
1,
3,
3,
2,
5,
and
and
and
and
4
5
3
6
34. The nurse monitors for signs of peritonitis, a potential
complication postoperatively. The manifestations
include the following except
A.
B.
C.
D.
Fever
Tachycardia
Abdominal tenderness
Soft abdomen
35. Intravenous therapy was prescribed. Which of the
following is not an indication of the therapy?
A.
B.
C.
To replace blood and fluid loss
For antibiotic therapy
For parenteral nutrition
D.
To promote renal function
Situation 8: Drug administration is one of the collaborative
functions of the nurse that require a written order of the
physician. To date, errors in medication continue to be a
problem in the health care setting across the globe.
36. A nurse is obligated to carry out a physician’s order
except
A.
B.
C.
D.
When the nurse is very busy
Believes an order to be inappropriate or
inaccurate
When the nurse does not understand the
order
When the client refuses
37. When do you carry out the order of the physician?
A. When the consent has been signed by the
client or any appropriate person
B. When the physician has signed the order
C. As soon as the medicine or therapy is
available
D. When the guardian of the client is present
38. A nurse encounters a client who refuses to take a
prescribed medication. What is the appropriate
action of the nurse?
A. Tell the client that he will be subjected to
another mode of treatment like surgery
B. Let the client sign the waiver
C. Explore the possible reason why the client
refuses the prescribed medication
D. Refer the client to the attending physician
39. In case of telephone orders, the concerned physician
needs to countersign the order within
A.
B.
C.
D.
The shift
As soon as possible
A time frame according to hospital policy
The day
40. The nurse should ensure that all components of
medications are documented. Identify all these
components.
1. Dosage, route and frequency
2. Name of client and medication
3. Date and time the medication was ordered
4. Dosage, route, frequency and strength
5. Physician’s signature and specialty
6. Physician’s signature and PRC license number
A.
B.
C.
D.
All
All
All
All
except
except
except
except
4
4
5
3
and
and
and
and
5
6
6
5
Situation 9: Nurse Mercy is assigned in the medical-surgical
unit and most of the clients assigned to her were elderly
clients.
41. For a client complaining of mild musculoskeletal pain,
the nurse will anticipate that the treatment for this
client’s level of discomfort will include which of the
following?
A.
B.
C.
D.
Diazepam
Acetaminophen
Meperidine HCl
Fentanyl
42. The nurse is to inject Vitamin B intramuscularly to
another elderly client. Before injecting, the nurse
explained that the client may feel some discomfort.
This is an example of
A.
B.
C.
D.
Reducing pain perception
Self-preservation
Anticipatory response
Distraction
43. Mr. Gomez, 71 years old, has a history of chronic
back pain. He thinks that his family perceives him as
a “weakling” because he often asks for pain
medication. Which of the following is the most
therapeutic response of the nurse?
A.
B.
C.
D.
“It seems that you are worried. Which
matter to you more? What people will say or
getting relief from your pain?”
“Taking pain medication as prescribed will
help you become more active and your
family will be happy to see you up and
about.”
“Chronic pain is very difficult to manage;
use pain medication because that is what it
is for.”
“Don’t you think your family wants you to
be comfortable, and the only way is to take
your medicine?”
44. Mang Pedring has chronic pain due to osteoarthritis
and has impaired speech. Which of the following is
the most appropriate to determine his medication
needs for pain?
A.
B.
C.
D.
Observe typical pain behavior through facial
expressions
Asking the client to rate his pain on a scale
of 0 to 10 by writing on a magic slate
Medicate the client with analgesic as often
as ordered
Record frequency of client’s complaint of
pain and administer medication accordingly
45. Aling Juana, 67, diabetic, complained of elevated
blood glucose since she strained her back a week
ago despite following her diet and drug prescription.
Your best explanation would be
A.
B.
C.
D.
Physiologic and psychologic stress can
elevate blood glucose level
Client is consuming more food as a coping
mechanism
It is a usual occurrence among the elderly
Parasympathetic stimulation from the
body’s normal response to pain
Situation 10: Research is essential to the development of any
profession. Through research, knowledge can be validated and
defined, and new knowledge can be generated. A team of
researchers proposed a study on the individual effect of
preoperative teaching on the early ambulation of women who
have undergone abdominal hysterectomy. Target populations
are women admitted on the same day for total abdominal
hysterectomy.
46. Which of the following is the most appropriate
method to use?
A.
B.
C.
D.
Non-experimental method
Qualitative method
Quantitative method
Experimental method
47. Which of the following designs would be most
appropriate to use in attempting to determine the
participants’ early ambulation after they will be given
preoperative teachings?
A.
B.
C.
D.
Time series design
Pretest – posttest control group design
Solomon four – group design
One shot case study
48. In the proposed study, the researchers defined the
selected groups and ask what sample size should be
used. Since there are many qualifiers that to some
extent samples must be specific to the study, the
general rule in the sample size is to
A.
B.
C.
D.
Determine the duration of the study
Consider the type of the study
Establish the number of variables
Make the sample as large as possible
49. The independent variable that is manipulated is
A.
B.
C.
D.
Women
Abdominal hysterectomy
Health outcomes
Preoperative teachings
50. In treating the data to be collected, the researcher
will use which of the following statistical tools?
A.
B.
C.
D.
Pearson r coefficient of correlation
Weighted mean
Chi square test
T-test
Situation 11: Pain brings client to the hospital more than any
other symptoms. Nurses should therefore be skillful to assess
pain and reduce discomfort both for the client and family.
51. Albert came to the hospital with chest pain and fever.
After a thorough assessment by the doctor, he was
admitted for pericarditis management. The nurse
positions the client to reduce pain and discomfort.
Describe this position.
A.
B.
C.
D.
Prone position with one pillow to support the
head
Put two pillows to elevate the head and one
pillow under the knees
Sit the client upright and lean forward
Supine lying on either left or right side with
one pillow to elevate the head
52. The nurse is aware that pericarditis pain varies from
mild to severe and is typically aggravated by
A.
B.
C.
D.
Coughing, talking and eating
Inspiration, coughing, movement of the
upper body
Breathing, coughing and voiding
Coughing, inspiration and movement of the
lower extremities
53. Albert’s mother asks why the client’s breathing is
shallow. The correct response of the nurse would be
A.
B.
C.
D.
“The client is conserving his energy.”
“That is good because the client is not
wasting the much needed oxygen.”
“He is preventing unnecessary movement.”
“Respiratory movement intensifies
pericardial pain.
54. Albert is prescribed NSAID every four hours to
relieve, fever, inflammation, and pericardial pain. To
maximize the effect of the drug, the nurse would
administer it
A.
B.
C.
D.
When the client asks for it
On an empty stomach
Round the clock on a consistent basis
When the client is awake only
55. The nurse wants to know if the client is aware of the
side effects of NSAID. What would be the most
appropriate question of the nurse?
A.
B.
C.
D.
“Are you aware that you can be addicted to
the drug?”
“Have you ever vomited blood or noticed
very black stools?”
“How familiar are you with the drug?”
“Have you noticed something unusual with
your urination?”
Situation 12: Nurse Carla admitted Harry for management of
acromegaly.
56. The nurse is aware that acromegaly is a condition
when growth hormone occurs in excess in adulthood
or after epiphyses of the long bones have fused. The
following are the typical features of the disorder
except
A.
B.
C.
D.
The soft tissues continues to grow
Hands and feet are enlarged
The client grows taller
Broad and bulbous nose
57. The client was prescribed Ocreotide acetate
(Sandostatin). Nurse Carla would monitor for which of
the following side effects?
A.
B.
C.
D.
Abdominal pain
Dysuria
Hypotension
Constipation
1. Taking the BP 15 minutes after intake of
antihypertensive drug
2. Measuring the BP after the client has
been seated for 5 minutes
3. Seating the client with arm bared
supported and at the heart level
4. Using the cuff with rubber bladder that
encircles at least 80% of the arm
5. Gauges of BP apparatus should be
calibrated every 8 hours
6. The client should rest quietly for 5
minutes before reading and can talk while
BP is being checked
58. For effective dosing, Ocreotide acetate must be
administered by which appropriate route, three times
weekly?
A.
B.
C.
D.
Intravenously
Intramuscularly
Orally
Subcutaneously
59. Priority discharge plans should include which of the
following?
1. Fasting blood sugar monitoring
2. Bone assessment
3. Intake and output
4. Urine output
A.
B.
C.
D.
2 and 3
1, 2, and 3
All except 1
1 and 2
60. Acromegaly often develops insidiously that nurses
should understand that the client with this disorder
would seek medical care because of
A.
B.
C.
D.
Alteration in fat and carbohydrate
metabolism
Changes in blood sugar level
Changes in appearance
Alteration in their voice
Situation 13: Part of your duty while on PM shift at the medical
ward is to give health instructions to clients and significant
others especially during visiting hours.
61. A client with gout asks the nurse what food must be
avoided so that the family can provide support.
Which food has the highest in purine content and
must be excluded from the dietary plan?
A.
B.
C.
D.
Chicken
Carrots
Chocolate
Liver
62. A 30-year-old client had cholesterol blood test before
admission to the hospital. The nurse in charge would
teach the family and significant others that the client
should exercise to help keep the total cholesterol to a
desired level of
A.
B.
C.
D.
140
200
250
300
mg/dl
mg/dl
mg/dl
mg/dl
63. A hypertensive client is taking herbal supplement for
his hypertension. He was prescribed antihypertensive
medication. The client wants to continue taking his
herbal medication to lower his blood pressure. The
nurse’s most appropriate action is to
A.
B.
C.
D.
Advise the client to discuss this concern
with the attending physician
Tell the client that herbal supplements have
no proven therapeutic effects
Tell the client that herbal and the prescribed
medications are not compatible
Instruct the client to have a more frequent
BP checking
64. The client was placed on a low sodium diet. The wife
asks the nurse which foods to include in the client’s
diet while at home. The nurse should instruct to
include which of these?
A.
B.
C.
D.
Canned foods
Preserved foods
Fruits and vegetables
Salt water fish
65. While the nurse was checking the BP of the client,
the wife was intently observing the nurse. The wife
asks the nurse how to ensure accurate measurement
of BP reading. Identify all the nurse mentioned that
will ensure accurate BP reading.
A.
B.
C.
D.
1,
3,
2,
2,
2,
4,
3,
4,
3,
5,
4,
5,
and
and
and
and
4
6
5
5
Situation 14: Marina, a newly hired staff nurse in the medical
surgical unit was assigned to work with a senior nurse. A
female client was admitted with a diagnosis of diabetic foot,
gangrene left toe, type 2 diabetes.
66. From the nursing history obtained from the client,
which information is most likely related to the
development of gangrene on the client’s left toe?
A.
B.
C.
D.
Preferred open toed sandals to closed
leather shoes
Type 2 diabetic diagnosed 15 years ago
Father had type 2 diabetes; post-aboveknee amputation right leg
Accidental cut in big toe while cutting toe
nails
67. The physician ordered bilateral lower extremities
Doppler ultrasound. Which of the following is the
physician interested to find out through this
diagnostic test?
A.
B.
C.
D.
Distal paresthesias
Oxygenation of the tissues in the lower
extremities
Occlusion of large vessels and arterioles
Isolated peripheral neuropathies
68. The senior asked Marina to list nursing interventions
for the nursing diagnosis “Ineffective tissue
perfusion: peripheral”. From the following list, which
intervention will the senior nurse consider to be
contraindicated?
A.
B.
C.
D.
Regular passive and active exercises of all
extremities
Keep extremities warm using a foot cradle
Encourage frequent changes in position
Maintain both extremities in a dependent
position
69. When Marina checked the capillary blood glucose of
the client at 6 PM before meals as instructed by the
senior nurse, the result showed 65 mg/dl. Which of
the following will Marina do first?
A.
B.
C.
D.
Give juice as prescribed in the insulin scale
pre-meals
Recheck CBG
Check the physician’s order in case CBG is
below 70 mg/dl
Look for the senior nurse and report
70. The senior nurse observes that Marina occasionally
does not follow agreed upon interventions. The
senior nurse reports that Marina should improve in
which of the following?
A.
B.
C.
D.
Identifying own learning needs
Attitute toward criticism
Compliance to standards
Demonstration of proper decorum
Situation 15: A 34-year-old female client with Grave’s disease
was admitted for treatment. The physician prescribed
Propylthiouracil to treat the disorder.
71. Before the nurse administers the medication, which
of the following is most relevant for the nurse to ask?
A.
B.
C.
D.
“Do you experience gastric discomforts?”
“When was the last time you tool alcohol?”
“When was your last menstruation?”
“Do you prefer a liquid form of medication?”
72. The client is to have surgery in 10 days. Lugol’s
solution 4 gtts po was prescribed in 10 days. The
client asked the nurse for the purpose of the drug.
Which response of the nurse is correct?
A.
B.
C.
D.
It decreases the risk of bleeding
It eliminates the needs to take hormone
replacement
It stabilizes your immune system to
withstand surgery
It decreases the risk for thyroid crisis
73. When the client returns to the unit after surgery,
which technique is most appropriate to monitor
bleeding from the incision?
A.
B.
C.
D.
Weigh all gauze dressing before and after
changing wound dressings
Assess for dampness at the back of the
client’s neck
Pass a flashlight across the incision wound
on top of the dressings
Remove the dressings to directly inspect the
incision wound
sons in the elementary. The head nurse emphasized
that it is her turn to go on PM duty. The action of the
head nurse exemplifies which of the following?
A.
B.
C.
D.
79. A scrub nurse is assisting an emergency Cesarian
section on a 39-year-old laundry woman. Before
closing the peritoneum, the surgeon asks, “How old
is the client?” Holding the fallopian tube, the surgeon
asks for a hemostat. The scrub nurse sensing that
the surgeon is about to ligate the tube said, “Doctor
there is no signed consent for tubal ligation.” The
nurse just demonstrated which of the following?
A.
B.
C.
D.
A.
B.
Falling blood pressure
Regular and noisy respiration
High fever
Spasm in the hand
D.
75. At the start of thyroid replacement post-total
thyroidectomy, the nurse must monitor for side
effects. Which side effects would the nurse expect to
assess?
1. Hypertension
2. Tremors
3. Hirsutism
4. Insomnia
5. Tachycardia
6. Hyperglycemia
A.
B.
C.
D.
3,
1,
1,
1,
4,
2,
3,
2,
5,
3,
4,
4,
and
and
and
and
6
6
5
5
Situation 16: The willingness of nurses to accept a set of
professional and ethical principles and apply it in their daily
affairs is the hallmark of a true professional.
76. A client is being positioned for radical vulvectomy
and a couple of clinical clerks wanted to come in to
watch the surgery. The circulating nurse advise them
to enter the OR suite later. Foremost, this decision of
the nurse is directed towards
A.
B.
C.
D.
Respecting the client’s rights
Preventing infection
Minimizing a crowd in the room
Preserving privacy
77. Nurse Kristine is to inject Demerol 75 mg to a postTURP (transurethral resection of the prostate) client
who is in pain. When she checked the narcotic
cabinet, she found out a vial that is almost empty.
She was able to aspirate 60 mg only. Nurse Kristine
decided to inject it instead of making the client wait
until the next Demerol vial is available. The action of
the nurse violates which of the following ethical
principles?
A.
B.
C.
D.
Justice
Beneficence
Truth
Autonomy
78. Nurse Nora is assigned on PM shift for the month of
June. She requested the head nurse if she can be on
night or morning instead to be able to tutor her 2
Insubordination
Abandonment of duty
Advocacy
Malpractice
80. An officer-in-charge signs a document for the chief
nurse who went on leave. The OIC signs her full
name over the name of the chief nurse. The proper
way to sign for the chief nurse who is on leave is
74. Which of the following assessment findings when
observed in a post-thyroidectomy client is indicative
of a thyroid crisis?
A.
B.
C.
D.
Authority
Fidelity
Autonomy
Justice
C.
Sign your name over the printed name of
the chief nurse
Write “for” before the title of the chief nurse
then sign your name above it
Erase the name of the chief nurse and write
your name then sign
Sign on a separate line as OIC
Situation 17: Sponge count should be performed by two
members of the surgical team in any surgical procedure where
there is a possibility that the sponge can be retained.
81. The scrub and circulating nurse should perform
sponge count during which phases of an abdominal
hysterectomy procedure?
1. Before the procedure
2. Before closing the endometrium
3. Before closing the peritoneum
4. At the skin closure
5. When the scrub nurse goes for a lunch
break
A.
B.
C.
D.
All except 5
All except 1
3 and 4 only
All except 2
82. The OR nurse knows that the correct way to count
sponge is
A.
B.
C.
D.
Scrub nurse counts singly followed by the
circulating nurse
Scrub and circulating nurse count by packs
of tens
Scrub nurse and circulating nurse count
audibly by packs of fifties
Scrub nurse and circulating nurse count
singly, audibly and concurrently
83. The scrub nurse and circulating nurse also counted
the sharps and miscellaneous items like instruments
before the procedure. Continuous accounting for
these items can primarily
A.
B.
C.
D.
Expedite the procedure thus shortening the
surgical time
Improve hospital miscellaneous revenue
Minimize injuries and/or liabilities to sterile
surgical team
Shorten surgical cases turnover by 15 – 30
minutes
84. The circulating nurse will document “surgical count”
in which of the following?
A.
B.
C.
D.
Observation notes
Intraoperative record
Nurse’s notes
Checklist
85. When the surgeon asked for suture to close the
abdomen, sponge count has not been completed.
Which of the following is the appropriate action of the
scrub nurse?
A.
B.
C.
D.
Requests the surgeon to recheck the
abdomen for sponges, if any
Continues to count the sponges
Hands obligingly the suture for closure to
the surgeon
Informs the surgeon that sponge count has
not been completed
Situation 18: The continuum of care is facilitated by effective
communication among the members of the health care team.
This activity is facilitated by documenting reports.
86. The change of shift report of nurses describes the
following except
A.
B.
C.
D.
Priority clients and impending needs
Client health status
Nurses priority needs
Client special needs
87. When the staff nurse on duty encounters a problem
that cannot be solved using nursing knowledge, skills
and available resources, it is best for the nurse to
consult the
A.
B.
C.
D.
Nurse supervisor
Medical director
Head nurse
Chief nurse
88. When the nurse ensures that the client has plan for
continuous care after leaving the health care facility
and assists from the transition from one environment
to another, she is doing a
A. Discharge plan
B. Admission plan
C. Referral
D. Nursing care plan
Answer: A
Rationale: “Discharge planning is the process of preparing a client
to leave one level of care for another within or outside the current
health care agency. Usually, discharge planning refers to the client
leaving the hospital for home. However, discharges occur among
many other settings. Within a facility it can occur from one unit to
another.”
Reference: - p. 113, Kozier et al, 2004
89. A nurse has to attend a committee meeting for two
hours. She delegates her work to another nurse.
What primary consideration should be observed?
A.
B.
C.
D.
Availability of resources
Time needed to perform delegated function
Willingness to assist
Competency to perform the given function
90. When a telephone order is made, it should be
documented by the nurse who is receiving the order.
The following should be included in the order to be
executed except
A.
B.
C.
D.
Time the call was made and its duration
Who made the call and who received the
order
What information was given and for whom
was the order
When the order was made and who made
the order
Situation 19: Nurse Abe receives a subpoena as a witness in a
court case.
91. Which of the following best describes the
responsibility of the nurse as a witness in a case of
court?
A.
B.
C.
D.
Protect the patient
State the truth
Collaborate with the primary physician
Relate a dramatic experience
92. Which doctrine is invoked if an abdominal X-ray of a
postoperative patient shows a forcep inside the
abdomen?
A.
B.
C.
D.
Force majeure
Borrowed servant doctrine
Res ipsa loquitor
Doctrine of captain of the ship
93. When the nurse is called to witness and was told to
bring the patient’s chart, what is needed to legally
summon the client’s chart in court?
A.
B.
C.
D.
Request order
Notarized letter from the complainant
Permission from the client
Subpoena from the judge
94. When Nurse Abe presents the patient’s chart as
evidence of a case, this is called a/an
A.
B.
C.
D.
Duces tecum
Appendices
Exhibit
Documentation
95. When a case is already filed in court, it is a court rule
not to discuss the matter outside the court. This is
A.
B.
C.
D.
Malpractice
Motu proprio
Subjudice
Sine-qua-non
Situation 20: A nursing student was assigned to take care of a
client with polycythemia vera.
96. You planned the nursing care of the client together
with the nursing student. You asked the nursing
student to enumerate the clinical manifestations of a
client with polycythemia vera. You expect the nursing
student to enumerate the following manifestations
except
A.
B.
C.
D.
Generalized pruritus
Hepatomegaly
Splenomegaly
Ruddy complexion
97. The nursing student reviews the laboratory findings
and finds which blood results are elevated?
A.
B.
C.
D.
RBC, WBC, and platelets
WBC, platelet, and cholesterol
Bilirubin, RBC, and platelet
BP, WBC, and hematocrit
98. Phlebotomy was ordered as part of the therapy. You
instructed the client and emphasized that the
procedure can be repeated. The client inquired,
“What is the primary aim of the procedure?” Your
appropriate response is
A. “It removes the excess blood and donate to
patients of the same blood type.”
B. “It prevents headache and dizziness.”
C. “It keeps the BP reading within normal
range.”
D. “It keeps the hematocrit within normal
range.”
99. The companion asks why the client was advised to
avoid iron supplements or vitamins. The correct
response of the nurse would be
A. “These supplements enhance the
production of RBC.”
B. “The vitamins and iron can suppress bone
marrow function.”
C. “Actually the patient does not need these
supplements.”
D. “It is best that the client gets these
supplements from natural sources.”
100.The client complained of generalized pruritus. The
following are appropriate nursing interventions
except
A. Administer routine antihistamine ‘round the
clock
B.
C.
D.
Regulate the temperature to 25 degrees
centigrade or lower
Bathe in tepid or cool water followed by
cocoa-based lotion application
Wear light material loose-fitting camisa